Outpatient Drug Rehabilitation Programs
1-888-781-7060

DRUG SOLUTIONS

  Alcohol Addiction
  Cocaine Addiction
  Crack Addiction
  Meth Addiction
  Heroine Addiction
  Methadone Addiction
  Codeine Addiction
  Demerol Addiction
  Dexedrine Addiction
  Dilaudid Addiction
  Ecstasy Addiction
  GHB Addiction
  Hydrocodone Addiction
  Lortab Addiction
  Marijuana Addiction
  Morphine Addiction
  Opiate Addiction
  Opium Addiction
  Oxycontin Addiction
  Percocet Addiction
  Percodan Addiction
  Ritalin Addiction
  Rohypnol Addiction
  Speed Addiction
  Ultram Addiction
  Vicodin Addiction

Assessment Form

Your Name:
Email :
Phone #:
Cell #:
Work #:
Address:
City: State:
Country:
Postal Code:

Person you wish to help ? self other   
     
If other, who are you concerned about: 
    Name:  Relationship:

How old is the addict ? 
 
Does the addict want help ? yes no 

Please list drugs abused: 
Primary:
Second:
Third:

How does the addict obtain drugs/alcohol ? 
    Works  Steals  Prescription  Deals  Other

Please describe any personal / family problems the addict has.


Please describe any legal problems the addict has.


Please describe the overall behavior & condition of the addict.


Is there any diagnosed medical condition? (Please describe)


Is there any diagnosed mental disorder? (Please describe)


Did the addict on any medication for any of the above? 
    yes no 
    Medication?  How long? 

Has the person ever attempted to stop using drugs before ?
    yes no 
     If so, by which method?
    Self  12-step  Non-Hospital Residential  Hospital  Other

If the addict has received treatment, please describe it. (Include name of the facility, 12-step, etc.)


Was it a private program or a state-funded program ? 
    private state-funded 
 
    Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)


Is there anything else you would like us to know?


    


Please fill out this information form as completely as possible so that we can provide you with the best help possible. We will help you find a good rehabilitation facility with a high success rate and which method does not use any kinds of drugs in the program which actually achieves a complete rehabilitation.
Top
 


1-888-781-7060

DRUG CENTERS

US Centers
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North
Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
Outpatient
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Wisconsin
West Virginia
Wyoming

Canadian Centers
Alberta
B.C
Manitoba
New Brunswick
Newfoundland
Nova Scotia
Ontario
Prince Edward
Quebec
Saskatchewan
Outpatient Drug Rehabilitation Programs
1-888-781-7060

Copyright © 2000 Drug Rehab Outpatient. All Rights Reserved
www.drugrehabnewyork.info
This Web site is provided to find drug rehab centers, drug addiction treatment, drug rehabilitation, drug and alcohol rehab centers, drug treatment centers or any drug rehab programs that works. Resources updated Jan 8/06